Predicting stress in first year medical students: a longitudinal study

While there is ample documentation that medical training is stressful, less is known about predictive variables that might identify students who have the most difficulty in managing stress during medical training. Depression and anxiety in first year medical students were investigated in a longitudinal design. One-hundred and twenty-one medical students (81% of the class) were surveyed. The first survey took place immediately prior to the beginning of medical training (wave 1); the second survey was approximately 8 months after the beginning of classes (wave 2). Medical students who began their first year with relatively low ‘A'level grades, high ratings of state anxiety and depression, high trait anxiety and low dispositional optimism, and reliance on avoidant coping strategies were found to be at higher risk for developing depression and anxiety symptoms at wave 2. Students reported increased concern about curriculum and environment, personal competence and endurance, and time to have a life outside medical school at wave 2, compared to their reports at wave 1. Increase in concerns correlated with an increase in depression and anxiety. At both surveys, use of avoidant coping strategies resulted in increased depression and anxiety; at wave 2, active coping and positive reinterpretation resulted in decreased depression and anxiety. These findings suggest characteristics of vulnerable students who might be identified early in their first year and provided with additional support. Educating students to expect an increase in concerns about environment and personal ability to manage the academic load might make these concerns less overwhelming. In addition, information about effective coping strategies (i.e. active coping efforts) and ineffective means of dealing with stress (avoidant coping efforts) might be helpful in preventing distress.     

American medical students in Israel: stress and coping

Medical students studying abroad have to adapt to a new cultural environment in addition to the usual stresses of medical school. This study explored the perceived stress and coping ability of students of the New York State/American Programme, Sackler School of Medicine, Tel Aviv University, who study medicine in Israel but are expected to return to America to practice. Students were surveyed using the Ways of Coping Checklist (WCCL), Appraisal Dimension Scale (ADS) and two instruments specifically designed for the study. The results supported the view that students having difficulty adapting to their new cultural environment also have difficulty at medical school. This pattern is a negative spiral in which anxiety and depression impair cognitive performance, which leads to academic difficulties and emotional distress. Improvements in student social support and primary prevention were implemented as a result of the study. Limitations of the study are discussed.     

Anxiety and study methods in preclinical students: causal relation to examination performance

Stress and anxiety are substantially raised in many preclinical students in their first year at medical school. Although correlated with poor end-of-year examination performance, anxiety levels did not cause poor performance, but were themselves caused by previous poor performance in sessional examinations. Study habits showed declining deep and strategic approaches, and increasing surface ('rote-learning') approaches. Surface learning correlated with poor end-of-year examination performance, and was a result of previous poor sessional examination performance. Deep learning did not correlate with performance, whereas strategic learning correlated positively with examination success, even when measured 2 years previously during application to medical school.     

Empathic processes: perception by medical students of patients'' anxiety and depression

Perceptions by medical students of patients' affective states were investigated, and the effect of the students' own emotions on such perceptions. One hundred and one fourth-year medical students rated the levels of anxiety and depression of three women patients presented on videotape, rated their own levels of anxiety and depression and completed a questionnaire on aspects of the rating process. Students had widely different and often inappropriate perceptions of patients' levels of anxiety and depression. Students who consistently overrated anxiety or depression in patients, compared to those who consistently underrated, were themselves significantly more anxious or depressed. These data suggest a need in medical education for systematic teaching of empathic skills and for recognition of potential bias in clinical decision-making arising from the clinician's own emotional state.     

Effect of anxiety on performance in multiple choice examination

Negative scoring of incorrectly answered multiple choice questions has logistic advantages, but may disadvantage anxious students. We therefore attempted to observe the effects of positive and negative marking of true/false questions on the examination performance of medical students with different levels of anxiety. Third-year medical students (141 men, 71 women) completed a Spielberger State-Trait Anxiety Inventory before an examination in pathology in 1994. Students knew there would be penalties for wrong answers in the first half of the examination and no penalties in the second half. Performance on the two halves was compared and effects of levels of anxiety assessed. Students reported slightly higher trait anxiety than American norms. Women students reported higher levels of state anxiety than men, and levels for both genders were indicative of a moderately stressful situation. Trait anxiety was not associated with performance in either the negatively or positively marked halves of the examination. For women students, but not men, lower state anxiety was positively associated with higher performance on the negatively marked half of the examination ( r = 0.29), but accounted for only 8% of the variance in scores. In our study, anxiety was correlated only slightly with results of a negatively marked examination. We conclude that anxious medical students are not unduly disadvantaged by this method of marking.     

A prospective analysis of stress and academic performance in the first two years of medical school

AIM: This study provides prospective, longitudinal data on the relationship between stress-related measures and academic performance during the first two years of medical school. METHODS: First year medical students (n = 121) were surveyed prior to beginning classes (wave 1), and again 8 months later (wave 2). Personality variables predisposing to distress (optimism and trait anxiety), stress response (depression and state anxiety), and stress management strategies were assessed at wave 1 and wave 2. Pre-medical academic scores, and grades at the end of five assessment periods over the course of the first 2 years of medical school were also obtained. RESULTS AND CONCLUSIONS: As expected, pre-medical-school academic performance strongly predicted performance in medical school. Academic performance before and during medical school was negatively related to reported stress levels. On bivariate correlations, there were numerous significant relationships between stress reported at waves 1 and 2, and medical school academic performance assessed after these measures. In addition there were modest negative correlations between self-reported coping strategies of 'humour' and 'wishful thinking', and consequent academic performance. However, the predictive value of stress and its management on prospective academic performance was much decreased once pre-medical-school performance was statistically controlled.     

Anxiety and stress reduction in medical education: an intervention

OBJECTIVES: To assess the effectiveness of a stress reduction elective on Year 2 medical students and to assess the sustainability of any noted improvement. METHODS: A new elective entitled 'Mind-Body Medicine: an Experiential Elective' was offered to Year 2 medical students. It was based on a course developed by the Center for Mind-Body Medicine. Enrolled students were surveyed on the first (time 1) and last (time 2) days of the elective and again 3 months later (time 3). Four validated self-report instruments were used to examine effects on anxiety, stress, mood states and depression. A comparison group of non-enrolled classmates completed the same instruments during the same timeframes. The study began in autumn 2004 and ended in June 2005. RESULTS: Participating students had higher initial anxiety scores than students in the comparison group. Anxiety in the study group declined significantly during the course, with enrolled students becoming indistinguishable from non-enrolled counterparts. These decreased anxiety levels were sustained for 3 months following the conclusion of the course. CONCLUSIONS: This elective was successful in attracting students who were more anxious than their peers. Enrolees had higher baseline anxiety levels than their peers. The course decreased anxiety levels. The significant drop in anxiety scores of the study group suggests that this mind-body elective was an effective way to decrease anxiety in these pre-clinical medical students. Decreases in anxiety were sustained 3 months after the course ended, indicating that the benefits of the course may be longlasting.     

Examination anxiety in medical students: experiences with the visual analogue scale for anxiety

Medical students' levels of anxiety under different conditions of stress were investigated, as well as the stability of anxiety ratings from one examination to another. After completing an end-of-term psychiatry examination, fourth-year medical students at Monash University were asked to score the Visual Analogue Scale for Anxiety (VASA) for three situational cues; usual day-to-day anxiety, highest anxiety associated with major exams the previous year and anxiety experienced in the end-of-term examination just completed. Twenty-eight weeks later students rated their anxiety in a subsequent end-of-term psychiatry examination. Most students rated themselves toward the lower end of the VASA for day-to-day anxiety and as having significantly, though not markedly higher anxiety in the end-of-term psychiatry examinations. The previous year's examinations, marking the end of pre-clinical training, provoked extremely high anxiety for most students, who achieved academically despite this. Comparison of anxiety ratings for the two end-of-term examinations indicated that VASA ratings shifted substantially for half the class. This variation suggests that students' levels of anxiety are not stable and predictable from one examination to another. Examination anxiety should not be seen necessarily as a consistent response to a specific and recurring situation. It is postulated that a range of situational factors and personal pressures, operating at the time, may determine how much anxiety is experienced as a reaction to the examination.     

Personality and performance in psychiatric education

An attempt was made in this study to develop a composite profile of personality characteristics of medical students that correlated differentially with successful achievement outcomes in the Psychiatry Clerkship at a University of Toronto teaching hospital. Data on 27 of 33 final year medical students in a psychiatry rotation programme were used to analyse canonical correlations between personality and achievement variables. The findings of the study indicated that success in clinical examinations was significantly correlated ( R = 0.64, P < 0.001) with a personality defined as apprehensive, anxious and less neurotic. Success on oral examinations was significantly correlated ( R = 0.37, P < 0.01) with a personality defined as anxious, more neurotic and extroverted. Success in objective multiple choice tests was not significantly correlated ( R = 0.21, P< = 0.10) with any particular personality profile, but the direction of the correlations suggested a personality describable as less intelligent (concrete thinking), apprehensive, adjusted and introverted. Although the small sample makes conclusions tentative, the findings are that students' personality differentially affect their examination results.     

The quality of medical teaching and learning in rural settings: the learner's perspective

Summary. During 1992–93, the authors produced a video-based teacher development resource kit for rural and isolated general practitioners and hospital medical personnel who are involved in medical teaching. As part of the development process, we surveyed 240 medical undergraduate students of the University of Queensland about their experiences and perceptions of teaching and learning in rural settings in Queensland. For approximately 90% of undergraduate learners, the experience with a rural medical practitioner was extremely positive. The major positive features identified by students were: being treated as a colleague; being allowed/encouraged to work independently; receiving feedback on their work; and being given ample 'hands-on' minor procedural experience and/or teaching. The 10% of students who reported unfavourably on their rural terms identified lack of opportunities to carry out solo consultations/work independently, lack of structure in teaching/learning experiences, and lack of hands-on experience as the major disappointments. The results demonstrate clearly how and why the majority of rural medical teachers in Queensland are effective facilitators of undergraduate learning.     

The quality of student-tutor interactions in the clinical learning environment

We surveyed 403 students in their clinical years for their perceptions of the quality of clinical clerkships. Between 42.6 and 67.0% of tutorials were said to contain positive factors such as a relaxed teaching atmosphere, enthusiasm, a good selection of patients and adequate preparation. Negative features in 18.2-37.2% of tutorials included unreasonable expectations, conflicting information, late arrival, early departure, failure to show up and the display of anger, a patronizing attitude, favouritism or ridicule. While two-thirds of tutors were regarded as friendly and helpful, the remaining one-third were perceived as unconcerned, discouraging, derogatory or hostile. Overall, only half the clinical tutors were rated as effective teachers; more specifically in medicine and psychiatry, less than one-third of consultants were regarded as effective teachers, as compared with some two-thirds of consultants in obstetrics and gynaecology and paediatrics who were so regarded. Almost two-thirds of the students had predominantly positive reactions to interactions with their tutors, in terms of being motivated to learn, enthused about the subject and having their self-confidence increased. Some one-quarter had negative reactions such as indifference, depression, anger, embarrassment and fearfulness. However, the impact of student-tutor interactions was mainly confined to the students' academic well-being, with little effect on their personal-social lives. Finally, one-third of students had experienced at least some form of mistreatment by their tutors, including gender, appearance, religious and racial discrimination, unfair grading and public humiliation. These findings suggest that the clinical clerkship may not be providing an optimal learning environment for medical students.     

Attitudes of medical students to old people: a cross-national comparative study

Medical students' attitudes to the elderly were compared at the start and finish of a 5-week clinical attachment in health care of the elderly at the Christchurch School of Medicine. The study investigated students in their first clinical year (fourth year of their medical course) over five terms using a questionnaire employing a Rosencranz-McNevin semantic differential scale to measure general attitudes to old age and a Likert scale to measure attitudes to medical care. A question was also asked about career preferences. There was significant improvement in attitudes measured by both scales (Rosencranz-McNevin P less than 0.001, Likert P less than 0.001). Students also showed an increase in interest in health care of the elderly as a career choice. When compared with two cohorts of students from Nottingham Medical School, attitudes were significantly better in the Christchurch group at the commencement of the run. Students at both schools showed an improvement in knowledge but this was more marked for Christchurch students.     

Primary knowledge, medical education and consultant expertise

We have studied the knowledge of students and clinicians that they actually used to follow up four problems in general medicine. Some unexpected similarities and differences in their readily accessible or primary knowledge were found in groups from first-year clinical medical students to consultants. There is no linear increase in the quantity of primary knowledge with experience, but qualitative changes are very much more important. At all levels individuals show a remarkable dissimilarity in the knowledge they use to solve clinical problems, so that the bulk of personal knowledge used is individual. Comparatively rarely do people use the same knowledge to solve any one clinical problem. However, there is evidence of a general tendency towards increasing uniformity in knowledge as a result of the medical school years. After houseman level, individuality increases again. These changes result in consultants achieving an identical profile to first-year clinical medical students in terms of the extent to which their primary knowledge bases are held individually or in common. These findings suggest that consultant expertise is actually based on individual experience rather than a common core of knowledge. The influence of medical school in providing such a common knowledge base is (1) limited and (2) reversed by clinical practice. The results suggest the necessity for increased vocational and practice-oriented components in medical education, particularly in postgraduate education.     

Attitudes to teaching among teachers at a British medical school

Summary. A random sample of clinical teachers at a British medial school was surveyed by postal questionnaire to assess their attitudes to teaching and to teacher training. The response rate among the 186 teachers sampled was 80%. A high degree of enthusiasm for teaching was detected despite a perception that teaching received neither sufficient priority within the medical school nor due recognition within its reward structure. Feelings were mixed concerning the quality of training which graduates received. However, only 5% of teachers believed their own teaching ability to be below average. This survey revealed considerable support for the concept of training courses for medical teachers, though feelings were mixed as to whether such courses should be compulsory. These findings are discussed and related to recent initiatives to improve both the status of teaching within medical schools and the quality of medical education.     

Women in medical school and beyond

The increasing proportion of female students in Australian medical schools warrants an appraisal of the particular factors which may influence their success in their undergraduate and post-graduate careers. Past shortages of medical manpower are giving way to a projected over-abundance of doctors in the near future.
New South Wales has three medical schools, and in 1979 women constituted a significant percentage of the total number of students entering the first year. In the Newcastle school that percentage has exceeded 50. Because the majority of women combine their careers with child-bearing and child-raising, they face special problems in medical school and beyond. The fulfilment of dual roles frequently creates significant conflicts for women, but there are signs that women are gradually overcoming such conflicts. In fact, some male students are now beginning to question their tradition of full-time commitment to a stressful profession with little free time left for their families or other interests.
To make the best use of medical manpower, planning towards more flexible training schemes and more innovative roles in medical practice is essential. Women in particular can help one another by co-operation and imaginative planning.     

Does medical training affect personality?

We have compared results obtained for psychometric tests (Cattell's 16 PF and Eysenck's personality inventory) on a cohort of medical students who sat the tests in their second medical school year and repeated them in their sixth and final year. Most of the changes were in the direction expected of students maturing through the 19-24 year age period, but there were some significant differences from those obtained by other workers using the same tests on general student populations. Thus, in our study male students became 'brighter', more 'emotionally stable', less 'timid', more 'tough-minded', and more 'self-controlled', all of these to a significantly greater extent than expected with the general student population. Similar changes were observed from females, although except for an increase in emotional stability, these were not significantly different from the values expected in the general population.     

Alcohol use among entrants to a Hong Kong University

AIM: This study of first year entrants to one of the major universities in Hong Kong describes the pattern of their alcohol consumption, their binge drinking, alcohol abuse, and dependence. METHODS: A retrospective cross-sectional study was conducted. A representative sample of year 1 students 2630/2968 (89%) newly admitted to the Chinese University of Hong Kong in 2003 were recruited to participate in a structured self-administered questionnaire. RESULTS: First year university students in Hong Kong have low rates of ever drinking alcohol (62%), and the rates of binge drinking and alcohol-related problems were 7 and 0.8%, respectively. The pattern of binge drinking is more common than weekly drinking (2.3%). Binge drinkers are more likely to have experienced alcohol-related interpersonal problems or (95% CI) = 6.5 (1.7-24.5). Males were more likely to drink, to binge drink, and to drink frequently. CONCLUSIONS: In contrast with students in the west, the majority of first year university students in Hong Kong are not binge or regular drinkers. However, there is a subgroup who smoke, drink more, and use alcohol as a means of coping with stress. This group may be particularly in need of a brief intervention, such as providing counseling and referral services.     

Medical student involvement in a major disaster

Five to six months after the deaths of 95 football spectators at Hillsborough football ground, senior clinical students at Sheffield Medical School were surveyed in order to assess their degree of involvement with the disaster. Approximately one student in eight could be said to have had a high level of involvement. Students with high involvement showed higher levels of distress on both the General Health Questionnaire and the Impact of Events Scale. Only a small minority of students attended psychological debriefing groups or counselling sessions, perhaps due to the stigma attached to professional help-seeking. The results have implications for medical training and provision of support within medical schools.     

中学生抑郁与其相关影响因素的综合研究

目的 探讨中学生抑郁状况与其相关因素的关系，以便为中学生抑郁问题的理论研究和辅导工作提供依据。方法 采用中学生抑郁量表、青少年生活事件量表、中学生父母教养方式量表、艾森克人格问卷和应对量表，对558名中学生进行调查。结果 中学生整体抑郁水平较低，但有32．9％的学生存在不同程度的抑郁问题，男女生在抑郁方面不存在性别差异；年龄差异在中学生抑郁上表现十分明显，高中生的抑郁状况要高于初中生。中学生抑郁情绪与生活事件、父母教养方式、人格和应对方式各因子均有十分显的相关关系；进一步回归分析结果表明，有6个因素对抑郁的预测作用十分明显，具体为不良情绪应对、内外向、学习压力、退避、神经质、父理解型教养方式。结论 中学生抑郁与生活事件、父母教养方式、人格和应对方式关系密切，受多种因素的影响。     

Adaptive and maladaptive perfectionism in medical students: a longitudinal investigation

OBJECTIVES: The personality of medical students may have an important impact on both their academic performance and emotional adjustment during medical school. There has been little systematic study of the impact of perfectionism on medical students. The present study sought to compare the perfectionism profile of medical students with that of a general arts student group and to examine the relationship among perfectionism, distress symptoms and academic expectations and satisfaction. DESIGN: Medical students (n=96) and arts students (n=289) completed a baseline assessment including two multidimensional perfectionism scales. The medical students also completed measures of distress symptoms, personality (neuroticism, conscientiousness) and questions about their perceptions of their academic performance. Of the medical students, 58 completed a second set of questionnaires 6 months later (time 2). SUBJECTS: First-, second- and third year medical students and first-year arts students. RESULTS: In comparison with arts students, the perfectionism profile of medical students showed higher personal standards, lower doubts about actions and lower maladaptive perfectionism scores. In the medical students adaptive perfectionism (achievement striving) was significantly correlated with baseline academic performance expectations and conscientiousness and was predictive of dissatisfaction with academic performance at time 2. Maladaptive perfectionism (excessive evaluative concerns) was significantly correlated with baseline distress symptoms and neuroticism and was predictive of symptoms of depression and hopelessness at time 2. CONCLUSIONS: Perfectionism in medical students differs systematically from perfectionism in general arts students. Distinguishing adaptive and maladaptive aspects of perfectionism is important in understanding the cross-sectional and longitudinal implications of perfectionism for medical students.